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A medication error trifecta!
From the June 12, 2002 issue
PROBLEM: A confused, agitated, and combative patient
was admitted to an ER with severe nausea, vomiting and a reported
seizure. His initial diagnosis was "viral gastroenteritis."
The patient had been taking WELLBUTRIN (bupropion) for
depression. Six weeks prior to his admission he was seen by
his physician, who gave him new prescriptions for all his medications.
But this time, he prescribed them using generic names. Unfortunately,
the patient continued taking his original prescription for Wellbutrin
and also started taking the new prescription for generic bupropion.
Around the same time, he attended a smoking cessation program
where he was referred to another physician who gave him a prescription
for ZYBAN (bupropion). Thus, he began taking Zyban, bupropion,
and Wellbutrin - all at the same time. The patient had given
the physician who prescribed Zyban a list of his other medications.
All three medicines were listed as "active meds" in
the physician's notes with no apparent recognition of the triplication.
The ER staff, unit nurses, pharmacists, the attending physician,
and a consultant neurologist also missed the error. A 3rd-year
medical student found the error after looking up the generic
names of all the patient's medicines. If the student had not
found the error, the reporter believes that the patient would
have been sent home on the same triplicate therapy, totaling
600 mg daily. Fortunately, the problem was noticed and the patient
was discharged from the hospital after 24 hours of intravenous
hydration.
Some pharmaceutical companies select different brand names
for products with the same active ingredient when it is FDA-approved
for different indications. In addition to Zyban and Wellbutrin,
other examples include PROPECIA and PROSCAR
(both finasteride), and SARAFEM and PROZAC (both
fluoxetine). Marketing issues may drive the practice of assigning
a new trademark when the same active ingredient is used for
a different indication, but other issues also may be involved.
For example, FDA allowed Lilly to use Sarafem for premenstrual
dysphoric disorder because Prozac (approved for depression,
obsessive-compulsive disorder and bulimia) may have a stigma
associated with it and women may not want to use it under
that name. Also, third party reimbursement may be available
only for certain approved indications (e.g., bupropion therapy
may be covered for depression [Wellbutrin] but not for smoking
cessation [Zyban]).
SAFE PRACTICE RECOMMENDATION: Multiple names for products
increase the likelihood of duplicate or triplicate therapy.
Duplicate therapy also may occur when branded generic products
are available from different manufacturers; when the same
drug is dispensed from two pharmacies under two different
names; or when one physician prescribes the product by its
brand name and another by its generic name (e.g., COUMADIN
and warfarin). Fragmented health care adds to the problem.
A good drug history is essential to prevent errors. Alert
patients to this problem and teach them the generic and brand
name of products when applicable. Encourage patients to keep
a medication list and bring it with them when they seek care.
Tell them to have their prescriptions dispensed from the same
pharmacy if possible. Manufacturers should clearly warn patients
on the package label and accompanying information that the
active ingredient is available under both names.
If you have encountered similar
problems, we would appreciate hearing from you! Please submit
reports to us at ismpinfo@ismp.org
by July 12, 2002. We also would like to hear your opinion
on this issue and any other error reduction strategies that
you think would be helpful.
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